Karnataka

Chitradurga

CC/40/2020

Sri.B.S.Shivamurthy S/o late Siddappa, - Complainant(s)

Versus

The Branch Manager,Star health and allied Insurance company ltd, - Opp.Party(s)

Sri.G.B.Prakash

22 Jul 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, CHITRADURGA.

CC.NO:40/2020

DATED: 22^nd July 2022

PRESENT: - Sri. G. SREEPATHI, B.COM., LL.B., MEMBER

       

                   Smt. B.H. YASHODA. B.A., LL.B., LADY MEMBER

 

                      

……COMPLAINANT/S	Sri.B.S.Shivamurthy S/o late Siddappa, . Advocate, Aged about 51 years,R/o #306, 2nd cross, Davalagiri Extension, Chitradurga town. Chitradurga.   (Rep. by Sri. G.B. Prakash)
V/S
.….OPPOSITE PARTY/S	1 . The Branch Manager, Star health and allied Insurance company ltd. No.48/1,28th cross, SIT main road,Tumakuru-572103 Tumakuru (Policy Issued Office)   2 . The Branch Manager, Star health and allied Insurance company ltd, #144,6th cross, Near Ajjaya temple, Jogimatti road, Chitradurga town-577501   (Rep by OP-1 and 2 Sri. K.P. Thippeswamy)

:ORDER:

 

Sri. G. SREEPATHI, B.COM., LL.B., MEMBER               

 

This is a complaint filed under section 12 of Consumer Protection Act, 1986 (herein after called as Act for short)

 

Through this complaint, complainant prays for award of compensation in favour of complainant against opponents to pay medical reimbursement amount of Rs.3,00,000/- as per policy under Family Health optima Insurance Plan, alongwith Rs.1,00,000/- towards pain, shock and agony and further prayed to award Rs.5,00,000/- towards cheating to the complainant for non settlement of policy medical reimbursement amount to the complainant on claim and its cause general expenses and cost at the rate of 12% interest from the date of Hospitalisation till the deposit by opponents with cost and grant other relief as this Hon’ble Commission deems fit by allowing this complainant.

 

2. It is alleged that OPs 1 and 2 are Insurance company, approached complainant for getting Health Insurance Policy by advising to cover the family health risk for one year period with the canvass and advise of OP-1 Company complainant availed Family health policy in the year 2017-18, 2018-19 and 2019-20 by paying premium of Rs.31,506/- per year. The Said premium amount was paid to OP-1 for the year                     2019-2020, for the same OPs have issued policy vide its No.P/141131/01/2020/001320 in complainant favour and cover Family Health risk since dated 27/09/2019 to 26/09/2020 and it covers medical treatment expenses to complainant and this Family upto Rs.13,50,000/- under Health optima Insurance plan. By obtaining said policy after making payment of premium, complainant became consumer

 

3. complainant submit that, At the time of obtaining policy OPs have assured to pay medical expenses to the complainant and his Family towards medical treatment by way of medical reimbursement of Hospitalization expenses for treatment. The complainant suffered with Benign Prostatic Hyperplasia (BPH) Acute Urinary Retention, for the same complainant took treatment at Manipal Hospital, Bengaluru from 14/10/2019 to 18/10/2019 as inpatient and undergone surgery on 15/10/2019 the Doctor there in done Transurethral Resection of the Prostate and intraoperatively (TURP) and Extravasations was noted so Abdominal Drain Kit (ADK) drain was placed intraperitoneal and complainant spend Rs.3,00,000/-. After discharge from the Hospital, complainant approached OPs company for reimbursement of medical expenses incurred for treatment during policy period, by submitting the claim alongwith all medical treatment Documents. Policy and other requirements as shown in the policy schedule. The OPs registered the complainant claim vide No.CLI/2020/14113/0680912 and the same was repudiated on 31-12-2019 without any reasonable ground and not shown any cause for repudiation of claim of the complainant. The act of OPs in rejecting the claim is illegal and oppose to law. The complainant surrender the Original policy for making payment of claim with proof of documents admission and discharge summary to OP-1 Company. Whereas they sent letter of repudiation. With this purpose of obtaining/ covering Family Health risk itself will be defeated and this complainant faced deficiency of service, mental agony apart from financial risk, faced hard days Cause of action arose to file this complainant on 31-12-2019 as OPs have issued repudiation letter and the same is within Jurisdiction. Hence filed this complaint.

 

4. Upon service of notice, Op’s appeared and filed their version. In the version OPs admitted about the Family Health optima Insurance plan, submitted that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy.  The policy terms and conditions specifically states that, the insured person/s shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance as the company may require in dealing with the claim.  Complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form.

 

5. That as per the OPs letter dated 03/12/2019 to submit following documents.

1. Letter from the treating Doctor stating the exact duration of Benign prostatic hyperplasia when was it first time diagnosed any past history of previous hospitalization for similar episodes.
2. All OPD consultation papers taken prior to this admission
3. Complete set of indoor case papers with operation theater notes
4. Copy of pan card of insured

 

6. Letter of 03/12/2019 was followed by reminder letter dated 18/12/2019, the insured has not submitted. So claim of complainant was repudiated on the ground of non submission of required mandatory documents and communicated to insured vide letter dated 31/12/2019.

 

        7. The OPs submits that the condition No-3 of the policy that is
“The insured person/s shall obtain and furnish the company with all original bills, receipts and  other documents upon which a claim is based and shall also give the company such additional information and assistance as the company may require in dealing with the claim”. OPs contended that on the basis of discharge summary of treating Hospital, as complainant has not co-operated for the same which is not payable as per condition No.3 of policy.

 

        8. Further in version filed by OPs, para-11, they have admitted to the extent of Bills produced Rs.2,18,699/- only “ The term of the agreement have to be  strictly construed to determine the extent of liability of the insurer. Also OPs submits that claim of Rs.1,00,000/- towards pain shock and agony and Rs.5,00,000/- towards cheating which is much more than hospitalization expenses will reveal the complainant is highly  vexatious and more benevolent provision of CP Act which is liable to be dismissed also on higher rate of interest highly exaggerated and without any basis.

 

        9. OPs submitting addition pleas, policy issued to complainant under which the dispute has raised is governed by limits of liability as per clauses. OPs have admitted that company is liable to pay the claim in term of contract of insurance issued to the claimant/ petitioner, submitted that maximum quantum of liability under term of policy shall be Rs.1,45,948/- on submission of original payment receipt for Rs.94853/- (As per attached annexure) Accordingly OPs pray for dismissal of complaint.

 

        Complainant himself examined as PW1 by filing affidavit evidence and documents are marked at Ex.A-1 to Ex.A-33.

 

        On behalf of OPs Dinesh.S.B., Senior Sales Manager examined as DW-1 by filing affidavit evidence and documents marked at B-1 to
B-8.Arguments of both side heard.

Now the point that arise for our consideration for the decision of complaint are that:

 

 Point No.1: whether the complainant proves that, the OPs have committed deficiency of service and he is entitled for compensation as stated in his complaint?

 

Point No.2:  What Order?

Our findings on the above points are as follows;

Point No.1: Partly Affirmative.

Point No.2: As per final order.

 

REASONS

        It is not in dispute that, the complainant has availed Family Health Policy in the year 2017-18, 2018-19 and 2019-20 by making payment of yearly premium of Rs.31,506/- to opponents Vide Policy No.P/141131/01/2020/001320   dated 27/09/2019 and the same was effective until 26/09/2020. Hence he became consumer Complainant admitted to Manipal Hospital, Bengaluru and took treatment for Benign Prostatic Hyperplasia,  Acute Urinary Retention from 14/10/2019 to 18/10/2019 as inpatient and undergone surgery on 15/10/2019 the doctor therein Transurethral Resection of the Prostate and intraoperatively (TURP) Extravasation' was noted so (Abdominal Drain Kit) ADK drain was placed intraperitoneal  and complainant stated he has expensed Rs.3,00,000/- and doctor who treated him advised to discharge on 18/10/2019 to get follow-up treatment within one week. After discharge from the Hospital, complainant approached OPs to reimburse the expenses incurred for treatment during treatment period by submitting the claim form along with medical treatment document policy and other requirements as per the policy schedule.
The OP’s register the complainant claim vide claim No.CLI/2020/14113/0680912 and repudiated the same without any reasonable ground and not shown any cause for repudiation even the complainant policy is covered under Family Health Optima Insurance Plan and the same was in force.

        2. In support of the contentions, complainant has relied on his affidavit evidence in which he has reiterated the contents of complaint. Complainant also relied on documents like inpatient final bill of supply and other documents for having availed treatment at Manipal hospital which were submitted to OPs for claim purpose and marked as Ex.A-1 to Ex.A-33.

        3. On the other hand OPs filed version admitting about the issue of policy and issued Repudiation letter dated 31/12/2019 by stating that, it is observed from the submitted discharge summary of the above hospital that the insured patient is diagnosed as Benign prostate hyperplasia, acute urinary retention. Hence we requested the insured to furnish the consultation reports, investigation reports and treatment details/follow up details and letter from treating Doctor stating the exact duration of Benign Prostate Hyper plasia, and Acute Urinary Retention. (As per Ex.A-1)

        4. In turn to substantiate the grounds of OPs they have cited a case in between Sony Cherian Vs Oriental Insurance Company Ltd., before the Hon’ble Supreme Court of India reported in 1999 (6) SCC 451 re-iterated the points highlighted in the said case, on perusal of the same we come to the conclusion that the same is not relevant to this case.

        5. That on perusal of case between Gurmel Singh V. National  insurance Co. Ltd., 2022 SCC online SC666 decided on 25.02.2022.
It is observed that.  Insurance companies are refusing claims in many cases on “flimsy grounds” The bench consists of Hon’ble Justice Mr.Shah and B.V. Nagarthna of  Hon’ble Supreme Court of India on 20^th May 2022, said while observing that, they should not be too technical while settling the claims and ask for documents that the insured is not in a position to produce due to circumstances beyond his control. Non settlement of claim can be said to be deficiency in service. Therefore, the appellant has been wrongly denied the insurance claim”. We have carefully gone through the records submitted by the complainant. It is seen that complainant has availed Family Health optima Insurance plan and OPs have repudiated the claim of complainant without proper reason and for irrelevant reason even though he has submitted all treatment bills and other documents. OPs failed to settle the claim of complainant.  Such being the reason complainant faced service deficiency from OPs and entitled for compensation as prayed in his complaint. Accordingly this

Point No.: 1 is held as partly affirmative.

Point No.: 2 For the fore going reasons, we pass the following;

 

 

::ORDER::

        It is ordered that the complaint filed by the complainant U/s 12 of CP Act 1986 is hereby partly allowed.

        It is ordered that the OPs are directed to pay Rs.2,18,699/- along with 6% interest P.A. from the date of complaint till realization. It is further ordered that, the OPs are directed to pay Rs.10,000/- towards compensation and Rs.5,000/- towards cost of this proceedings to the complainant.

It is further ordered that, the OPs are hereby directed to comply the above said order within 30 days from the date of order.

Communicate the order to parties.

 

 (This order is made with the consent of Members Typed directly on the computer to the dictation given to stenographer, the transcript corrected, revised and then pronounced by us on  22^nd July  2022.)

 

 

 

 

 

LADY MEMBER                                                       MEMBER                           

 

-:ANNEXURES:-

Witnesses examined on behalf of Complainant:

PW-1:-B.S. Shivamurthy S/o Late Siddappa.

 

Witnesses  examined on behalf of opponents:

DW-1:-Disesh S.B., deponent.

 

Documents marked on behalf of Complainant:

01	Ex-A-1:-	Repudiation of Claim letter dated 31/12/2019
02	Ex-A-2:-	Discharge summary dated 18/10/2019
03	Ex-A-3:-	In-Patient Final Bill dated 18/10/2019
04	Ex-A-4:-	Policy Schedule Proposal dated 27/09/2017
05	Ex-A-4(1):-	Accident care individual Ins. Policy Schedule Renewal Endorsement No.P/141131/02/2019/000149
06	Ex-A-4(2):-	Accident care individual Ins. Policy Schedule Renewal Endorsement No.P/141131/01/2020/001320
07	Ex-A-5:-	Renewal Notice dated 04/08/2018
08	Ex-A-5(1):-	Renewal Notice dated 28/06/2018
09	Ex-A-6:-	Adhar Card
10	Ex-A-7:-	Pan Card
11	Ex-A-8:-	Out Patient Record dated 31/10/2019
12	Ex-A-9:-	Request Form for Radiology and Imaging Tess dated 20/09/2019
13	Ex-A-10:-	Scanning copy dated 14/10/2019
14	Ex-A-11:-	Echo Cardiography Report dated 14/10/2019
15	Ex-A-12:-	Abdomen Ultrasound dated 11/10/2019
16	Ex-A-13:-	Biochemistry clinical Laboratory report dated 17/09/2019
17	Ex-A-14:-	Microbiology clinical Laboratory report dated 17/09/2019
18	Ex-A-15:-	Haematology clinical Laboratory report dated 14/10/2019
19	Ex-A-16:-	Histopathology clinical Laboratory report dated 01/10/2019
20	Ex-A-17:-	Consultation of Urology Bill of supply dated 14/10/2019
21	Ex-A-18:-	Registration, Bill of supply dated 17/09/2019
22	Ex-A-19:-	Consultation of Urology Bill of supply dated 17/09/2019
23	Ex-A-20:-	Pharmacy Bill dated 18/10/2019
24	Ex-A-21:-	Pharmacy Bill dated 31/10/2019
25	Ex-A-22:-	Pharmacy Bill dated 20/09/2019
26	Ex-A-23:-	Pharmacy Bill dated 01/10/2019
27	Ex-A-24:-	Uroflowmetry Bill of supply dated 31/10/2019
28	Ex-A-25:-	Bill of supply dated 17/09/2019
29	Ex-A-26:-	Bill of supply dated 20/09/2019
30	Ex-A-27:-	Bill of supply dated 14/10/2019
31	Ex-A-28:-	Bill of supply dated 14/10/2019
32	Ex-A-29:-	Bill of supply dated 01/10/2019
33	Ex-A-30:-	Bill of supply dated 01/10/2019
34	Ex-A-31:-	Manipal Hospital Receipt dated 18/10/2019
35	Ex-A-32:-	Advance Receipt dated 14/10/2019
36	Ex-A-33:-	Inpatient Interim Bill of supply dated 18/10/2019

 

 

Documents marked on behalf of opponents:

 

01	Ex-B-1:-	Common Proposal Form  dated 27/09/2017
02	Ex-B-2:-	Kind Attention: policy holder Description
03	Ex-B-3:-	Claim Form Part-A
04	Ex-B-4:-	Discharge Summary dated 18/10/2019
05	Ex-B-5:-	Letter correspondence for additional documents/information dated 03/12/2019
06	Ex-B-6:-	Letter correspondence for additional documents/information dated 18/12/2019
07	Ex-B-7:-	Repudiation of Claim letter dated 31/12/2019
08	Ex-B-8:-	Bill Assessment Sheet Bill approved dated 21/09/2020

 

 

 

LADY MEMBER                                                       MEMBER                           

  

 

 

 

 

 

 

 

 

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